Science You Can Use: Cesarean birth without labor associated with breastfeeding problems, say two new studies.

Two studies out this year are have reached a troubling conclusion: cesarean births without labor are associated with breastfeeding difficulty.

This is troubling because for many women a planned cesarean is their only in-hospital birthing “option.” More on that in a moment. First, to the research:

The first study, a large meta analysis of research on breastfeeding and cesarean births, included 48 studies reflecting the experience of over 550,000 subjects. It found that “rates of early breastfeeding (any initiation or at hospital discharge) were were lower after cesarean delivery compared with after vaginal delivery and lower after prelabor but not after in-labor cesarean delivery.”

A second study looked at the weight loss of 200 exclusively breastfed babies delivered by cesarean section in a U.S. Baby Friendly hospital, almost half of which did not undergo labor prior to delivery. It found that “absence of labor prior to delivery was significantly associated with a greater percentage of weight loss,” and concluded “for exclusively breastfed infants delivered by cesarean birth in a Baby-Friendly hospital, absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss.” Excessive weight loss isn’t a breastfeeding outcome per se, but higher weight loss in the first few days after birth often leads to supplementation, which in turn is associated with shortened duration and less exclusivity of breastfeeding.

Why would cesarean birth without labor pose these risks? As I’ve written before, cesarean births in general are associated with a number of breastfeeding issues. With respect to cesarean births without labor, the authors of this second study point to a number of possible explanations: “the complex and incompletely understood endocrine and neuroendocrine mechanisms that regular labor,” greater fluid retention in the infants’ lungs, and lower gestational age at birth.

Let’s zoom in on this last factor – gestational age – for a moment, because I think that the implications are quite staggering.

We know that the vast majority of repeat cesareans are planned and do not involve labor. We also know that many planned cesareans are performed electively (for no medical reason) before 39 weeks of gestation. One study found that, of 13,000 elective repeat cesareans, 36% were done prior to 39 weeks gestation (in the study referenced above the mean gestational age was 39 weeks, so a good number were likely born before). This in itself is a risk factor for a number of problems, including breastfeeding problems and problems that have a direct effect on breastfeeding (respiratory issues, hypoglycemia, admission to NICU), as we’ve discussed before. Babies born in this range are known among breastfeeding support people as “impostor babies” because their size often masks their immaturity when it comes to feeding.

I find the conclusions of these studies particularly troubling because for many women, a planned cesarean without labor is the only in-hospital birth available to them.

Of course, there are a number of reasons why mothers might not be able to experience labor before a cesarean, such as maternal or fetal complications, and multiples or breech presentation where vaginal delivery is not practiced.

So, to connect the dots: Cesarean birth without labor appears to be a risk factor for breastfeeding difficulty. Babies born by planned cesarean are frequently delivered early for no medical reason – a risk factor for breastfeeding. Most women having second and subsequent babies after a c-section have no in-hospital choice besides a cesarean birth without labor.

What are the implications of these findings for mothers and providers?

For providers, it may be that this and future research will establish that cesarean birth without labor is a risk factor for breastfeeding problems, and appropriate support will be provided.

21 Responses to Science You Can Use: Cesarean birth without labor associated with breastfeeding problems, say two new studies.

I had an emergency c-section at 27 weeks with my surrogate twins in November 2011. After surgery I started pumping and I’m still pumping to this day (9 months)! I’ve had absolutely no problems with lactating although this might be different if I had to keep the twins myself. I produce anywhere from 29-33oz each day.

I had two planned c-sections due to my medical condition. Since 39 weeks fell on a Saturday, I had my son the following Tuesday, and my daughter the Friday before. Both times I managed to Breastfeed. In the casepf my son, the stupid anesthesiologist(sp?) made me wait 8 hours and then gave me general anesthesia anyway (against my protests). I don’t know if it’s because this was my first child or if it was effects of the drugs, but there were a few latch problems. I had very supportive nurses. My mill was in by the time I left the hospital.
My daughter also had mild latch issues, but were quickly fixed by changing positions. As I had still been nursing my son (then 22 months) my milk was already in.
I think having supportive nurses and family was the big factor in being successful.

I had three c sections total. Two were planned after the first was an emergency section. I was blessed that I had no trouble nursing any of my babies. I was also blessed that with my planned c section for baby #2 my water broke that morning before we went to the hospital. With my third baby we did not even get to the scheduled date before my water broke. She was born a week before my scheduled date. She is now 11 months and nursing well. BTW I nursed my older two to 25 and 30 months respectively with only a minor problem when the oldest got a cold at 8 wks.

I had one unplanned csection with my first son and the second was a failed VBAC and both experiences were completely different. In the first, I felt the attending doctor and hospital pressured us into the csection and I truly felt the labor process was out of my hands and out of my control. I ended up having a lot of issues with latching/milk coming in and later with supply. I consulted a lacation specialist and took the herbal motherlove and it was still a very hard go. I also had PPD with the first delivery and very much feel to this day it was how the scenario of my labor went. With my daughter (I had her 2 months ago) I did try for a VBAC but stalled out and after being in labor for over 24 hrs it was decided we needed to do a cection but I didn’t have any of the same problems. I think it was because my doctor and staff were so supportive of my labor plan and really made sure I felt I had done everything in my power to proceed naturally. Breastfeeding is hard enough but when there is a lack of support or you feel out of control I feel that this has a huge impact on your emotional well being and milk supply.

I had an unplanned c section at 38 weeks when my midwife found me 3 cm dilated, bulging water, and the baby was footling breach. Seven hours later my daughter was born, with no labor at all. She had a birth defect, TEF, where her esophagus wasn’t connected to her stomach and had to have surger to fix it. It was 2 weeks before she’d healed enough for us to start nursing, but the hospital and NICU staff were very supportive of breastfeeding and pumping, “rented” out hospital grade pumps for NICU mommas for free, and had a IBCLC on staff available to help with any problems. So while there were a few challenges for us to breastfeed, we were able to get on the road with very few bumps to hinder us.

I’m expecting our second now, and am definitely hoping for a natural birth this time around. I do feel like breastfeeding will be easier with a natural birth.

One of the most important things that is very often missed in discussions about whether planned cesarean birth may have an adverse effect on breastfeeding is this: Did the women WANT to breastfeed in the first place? Some women simply don’t want to breastfeed, and may not even try to, so their ‘absence’ of breastfeeding is not necessarily related to the mode of birth (or planned mode of birth) at all.

In the “Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature” research that you cite for example, there “was a negative association between prelabor CD and early breastfeeding.” [BUT] “If breastfeeding is initiated, mode of delivery has no apparent effect on the number of mothers still breastfeeding at 6 mo.”

And in the “Weight Loss in Exclusively Breastfed Infants Delivered by Cesarean Birth” research, looking at the Abstract, the authors do not appear to have measured the weight loss at babies born at different gestational ages. So while it’s possible that “absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss”, we don’t know for sure if this correlation is worse at earlier gestational ages – or at 39+ gestational weeks too (which guidance recommends waiting until unless there are medical or obstetrical indications).

Love your comment Pauline – I think it’s hard for people to write articles/look at research completely unbiased (myself included). We pull out what we want to pull out to support our opinion. From reading through the comments, it seems many Mom’s who wanted to BF and did not go through labor actually were successful, although, it may have taken some time. Thanks for looking into the research and posting the other parts that are important.

I had a scheduled c-section st 38 weeks because my son was breech. Didn’t have a single contraction but I had no issues whatsoever with breastfeeding. I consider myself lucky but now that I know more I wouldn’t choose that again if I could avoid it.

Three c-sections here. I only had problems breastfeeding the first child (and unplanned c-section at 41 weeks). That was due to a jaw deformation he had, not because of the way he was born. (So I pumped for a year and bottle fed him breast milk).

Like Pauline said, I *WANTED* to breastfeed and so when the nurses told me not to sit up right after I had my second son to breastfeed because the anesthesia would make me sick, I just waited until they left the room to sit up and successfully breastfeed my baby.

I wasn’t aware of the term “imposter baby” until this article and that describes my third child. She was born via planned c-section at 38 weeks and was a very sleepy eater. Guess what? I was still determined to breastfeed her. And here she is 5 months old and still going strong.

Looking at the other comments it appears that breastfeeding among c-section mothers is something they WANT to do and they stick with it despite the challenges. Which I’m going to guess, I’m no scientist or statistician here, is probably what ALL breastfeeding moms do no matter HOW they delivered their babies.

I had a cesarean WITH labor and I still had all of these problems! I almost think this article was written about me & my LO. Hoping that when the next one comes along, if we go through with a planned c-section, that we can communicate well with the Dr our concerns about breastfeeding & weight loss that we didn’t even know were concerns with our first!

Thank you for your article and for bringing potential c-section challenges to light. I have written a book called Milk Diaries – a compilation of practical, encouraging advice from the real breastfeeding experts, wherein 30+ women share their stories of trials, triumphs, and everything in between). It should hit Amazon’s virtual bookshelves in a matter of days. Here’s an excerpt that talks to this point:

… I had the opportunity to talk to a lot of moms while compiling this book. I was astounded at the number of moms who truly, madly, deeply wanted to nurse their babies and couldn’t because “their milk never came in.” To be honest, my initial thought was that they didn’t give themselves enough time. I do not mean they didn’t TRY. I mean they didn’t realize that although it usually takes 3-4 days for milk to really come in, that it can sometimes take as long as two weeks (in which case short-term supplementation would obviously be necessary).

Experts cite many reasons this can happen…excessive blood loss during labor and delivery…if the entire placenta doesn’t pass…inability to get skin-to-skin contact right away after birth. While these are all valid reasons, I would say another big culprit is stress. And, really, who would argue that a mother who just underwent labor isn’t stressed? I would contend that all the pressure of fulfilling this one maternal task only a mother can perform—along with all the other stressors that go along with being a new mom—is enough to throw any mom’s body out of whack for a while!

Stress can be compounded when drugs are involved during labor and delivery. Although they have not found the drugs themselves to affect breast milk, they can affect the hormones associated with breastfeeding. Some pain medications (especially those used during and after a C-section) elevate dopamine levels which in turn inhibit prolactin’s job of making milk. (Those same drugs—used for epidurals and c-sections alike—may also cause you to have flat nipples. See Holly’s story on page 141 and Zoë’s story on page 193 for more on flat nipples.) Oxytocin, the hormone responsible for letdown, is also affected by stress.

If your milk isn’t coming in “right away,” there are some things you can do to coax it out. Trying to nurse early and often as well as pumping between attempts will hopefully yield some results. I would also say that cutting yourself some slack for all that your body has just endured, resting whenever possible, and finding ways to relax can go a long way. You aren’t Supermom, and that’s ok. It will take a village to raise your baby, and it might just take a village to get nursing off to a good start, too. Take a deep breath, accept that it’s a tough situation (but one that’s hopefully worth getting through), and do what you can. Sometimes your body will slowly but surely cooperate. However, sometimes the advantages will never outweigh the disadvantages and supplementing or completely switching over to formula is the best option. See Peggy’s story on page 75, Kelly K’s story on page 91, Kelly S’ story on page 117, K.C.’s story on page 199, and the Weaning section on page 43 for more on this topic.

#1 was with my eldest which was initially going to be an emergency c/s, but was then downgraded. My son went into special care via NICU straight after birth so breastfeeding was significantly delayed and difficult.

#2 was recently (scheduled at short notice due to oligohydramnios (sp?)) and we started breastfeeding as soon as I was in recovery/postnatal and apart from tongue tie issues, which were fixed the day after the birth, we haven’t had any problems at all.

My first was emergency c section at 31 Weeks so of course there was breastfeeding issues buy I did not give up.it took him about 3 months to learn to breastfeed. It was very very difficult but I’m not really discouraged. =)
My second,my husband and I decided together that a c section was or way to go. Originally planned for two Weeks before my due date but I requested it be done 3 days before my due date & my Dr had no problem with that. Our first attempt to nurse was great! Latched on right away and she nursed for a half hour! They told me she might only go for about fifteen minutes.

I did have a planned c-section at 38 weeks with my first child in 2009 because she was breech. I hated it. I felt very disconnected from her & breastfeeding was extremely difficult. It was almost 3 weeks before I got the hang of it & 3 months before I was able to breastfeed without formula supplementation.
With my second I had a VBAC. I found a supportive doctor in our state and rode an hour and a half for every visit. I gave birth with in 2011 to him & the difference between the 2 is astounding. He nursed much better, although due to a miscalculation in his due date he was also 38 weeks instead of 40. (I had to be induced because of high BP).
So glad that research has backed up what I KNOW I felt!!!

I am pro breast feeding all the way but I sometimes feel that while facts and studies may serve a school of thought, one needs to analyze these in whole and without personal opinion. Do I believe things that are standard practice for hospital delivery affect the ability to nurse our babies? Absolutely. In this case though, a planned cesarean without labor may be the only indicated method for safely guiding mother and child through birth. Many mothers now have more serious underlying medical issues which in the past might have prevented or steered them away from childbearing, I am one of those mothers. My pregnancies have been challenging, both deliveries were cesarean and I had an imposter baby. Oldest delivered at 38 weeks due to my diabetes, lack of progress during induction and early signs of fetal distress. My youngest was delivered shy of 37 weeks at nearly 11 pounds, had severe hypoglycemia and was transferred to another hospital within 12 hours of birth. I did not see him until eight hours post op and only ten minutes. All of these things affected my ability to breast feed and neither were done exclusively but my six month old is STILL breast fed despite his birth and the many obstacles that followed. The most important thing is my children are alive, well and thriving, and I don’t consider that to be a failure. I know it’s not intended but a person in my situation might feel like a less worthy mother for opting for safety over what nature created a mother to do. Please consider our feelings when conveying this kind of material, no one wants to feel inferior.

2 cesareans….first was an emergency one after a grueling labor an two hours of active pushing. I almost died an so did my baby. But we survived and he breast fed like a champ!

2nd baby was a planned CS at a very pro BFing hospital. No issues nursing at all and milk came in perfectly fine.

I think articles like this adds to a mothers anxiety about having a CS if it is deemed medically necessary. If it were me and I didn’t know any better…I’d be a basket case thinking I’d have issues BFing due to a CS. It already puts a negative thought in the mother’s mind during an already scary time.

My wife had cesarean 3 days ago and is unable to breast feed. there were 5 cesarean scheduled that day and in 4 of the cases including that of my wife they have the common inability to breast feed.. this cant be a coincidence…

Very good review! I would be most grateful if you could give the refs for those two studies. Also, in the second studies (excessive weight loss), what percentage of babies had >10% weight loss? In the group of excessive weight loss, what percentage of babies received a supplementary feedin with formula, if any?
Regards,
Krys Lubkiewicz M.D.

Links to the studies are in the post (let me know if you can’t get to them). The answers to your questions aren’t in the abstract for the second study, but if you have access to the full text they should be there. Let me know if you don’t have access and I’ll look for you.